ADR NEUTRAL NAME, ADDRESS, TELEPHONE, FAX AND EMAIL: Reserved for Clerk’s File Stamp STATE BAR NUMBER SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES COURTHOUSE ADDRESS: PLAINTIFF: DEFENDANT: APPLICATION AND MOTION FOR COMPENSATION FOR VIOLATION OF COURT RULES RE ARBITRATION/MEDIATION AND DECLARATION IN SUPPORT THEREOF CASE NUMBER: 1. TO (name of plaintiff/petitioner): ____________________________________________________________________ 2. Arbitrator Mediator (Neutral name), _____________________________________________, hereby applies for compensation in the amount of not less than $150 and not to exceed $450. 3. A(n) arbitration mediation was scheduled for (date) ________________, at (time) __________ a.m. p.m. 4. Said compensation is requested for: Failure to provide notice of settlement of the action. Failure to provide notice of settlement of the action at least 2 days before the scheduled hearing or session. Notice was received on (date) ________________ by fax letter telephone call. 5. Specific facts in support of compensation are: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: _____________________ ........................................................................................... _____________________________________________ (TYPE OR PRINT NAME) (SIGNATURE) ADR052 01-05 (Rev. 01-07) APPLICATION AND MOTION FOR COMPENSATION FOR VIOLATION OF COURT RULES RE ARBITRATION/MEDIATION AND DECLARATION IN SUPPORT THEREOF Cal. Rules of Court, rule 3.1385 LASC Rules, rules 7.9(f) and 12.5 Page 1 of 2 [NO FILING FEE OR FAX FILING FEE REQUIRED] American LegalNet, Inc. www.FormsWorkflow.com Short Title Case Number ORDER 6. A hearing on this motion for the compensation requested above will be held as follows: a. Date: Time: a.m. p.m. Dept. Div.: Rm.: b. Address of courthouse: Same as noted above. Other (specify): 7. Any responsive declaration must be filed with the court at least three court days before the hearing date. 8. The clerk is ordered to give notice of hearing to all counsel of record or parties in pro per and neutral forthwith. Dated: _____________________ ____________________________________________ JUDICIAL OFFICER CERTIFICATE OF MAILING I, the below named Executive Officer/Clerk of the above-entitled court, do hereby certify that I am not a party to the cause herein, and that on this date I served the Application and Motion For Compensation For Violation of Court Rules Re Arbitration/Mediation and Declaration in Support Thereof upon each party or counsel named below by depositing in the United States mail at the courthouse in ________________________, California, one copy of the original filed/entered herein in a separate sealed envelope to each address as shown below with the postage thereon fully prepaid. JOHN A. CLARKE, Executive Officer/Clerk Dated: _____________________ ADR052 01-05 (Rev. 01-07) By: _________________________________________ Deputy Clerk APPLICATION AND MOTION FOR COMPENSATION FOR VIOLATION OF COURT RULES RE ARBITRATION/MEDIATION AND DECLARATION IN SUPPORT THEREOF Cal. Rules of Court, rule 3.1385 LASC Rules, rules 7.9(f) and 12.5 Page 2 of 2 [NO FILING FEE OR FAX FILING FEE REQUIRED] American LegalNet, Inc. www.FormsWorkflow.com